Membership Application Membership Application First Name * Position of Interest Interior Structural Firefighter Fire Police Junior (Under 18) Administrative Join Us Middle Initial * Last Name * Date of Birth (MM/DD/YYYY) * Age * Street Address * City, State, Zip * How long have you lived at this address? Home Phone Number * Cell Phone Number Place of Birth (City, State) * Email * Do you currently have any of these certifications? NJ Firefighter 1 NJ EMT-B NJ Paramedic New Jersey Fire Police Are You A United States Citizen? * Yes No Are You A Licensed Driver? Yes No If so, how long have you been driving the following?: Passenger Auto: Truck: Bus: Have You Had Any Accidents In The Last 3 Years? Yes No Have You Ever Had Your License Suspended? * Yes No Drivers License Number Select Licensed State New Jersey New York Other: Please explain below. Other State? Select Drivers License Type Basic Drivers License (Class D) Commercial Drivers License (Class C) Commercial Drivers License (Class B) Commercial Drivers License (Class A) Have You Ever Been Convicted Of A Crime? * Yes No Will You Permit A Police Dept. Records Check? * Yes No Will You Consent To A Driving Abstract History Check? Yes No Signature * By checking this box you are declaring all the above answers are true to the best of my knowledge and belief. It is understood that any false statement on this application is sufficient cause for rejection or dismissal. Also if acceptance is obtained under this application, I further agree to comply with all orders, rules, and regulations of the Robertsville Vol. Fire Company. I further agree to submit to a physical examination. How did you hear about us? Submit If you are human, leave this field blank.